key: cord-011656-zln7zmn9
authors: Subedi, Asish
title: Medical Ethics Versus Healthcare Workers’ Rights: Fight-or-Flee Response
date: 2020-06-16
journal: Anesth Analg
DOI: 10.1213/ane.0000000000005060
sha: 
doc_id: 11656
cord_uid: zln7zmn9

nan

To the Editor I read with great interest an article by Bong 1 on coronavirus disease 2019 (COVID-19) impact on low-and middle-income countries (LMICs). This article deals with the several health care problems faced in LMICs, and the authors have provided solutions to overcome it.

Before I share my views, I would like to introduce my current workplace. I am working as an Anesthesiologist in a tertiary care hospital situated in the eastern part of Nepal. My country is sandwiched between 2 big giants, China and India. While China has flattened the COVID-19 curve, India is between stages 2 and 3 of the coronavirus pandemic. As of April 17, 2020, Nepal has reported 16 confirmed cases (14 active and 2 recovered), with no casualty. The Government of Nepal imposed the lockdown timely to combat COVID-19 spread and is planning to extend the ongoing lockdown. Although social distancing limits the virus spread, it is not the only solution. Moreover, with a porous border with India, there is a high chance of importing the virus. Perhaps, we are just 1 month behind from where India is in the current situation.

This has caused fear, panic, and anxiety among us-the frontline health care providers. It is the same feeling before doing the bungee jump. A recent survey revealed that nearly half of the health care workers treating COVID-19 patients experienced symptoms of depression, while about one-third of them suffered from insomnia. 2 This report highlights the importance of psychological well-being of health care workers involved during the COVID-19 tsunami. Unfortunately, mental health is often neglected in our part of the world. To overcome the mental stress, the government should provide social securities and incentives to health care workers, and moral support to reassure how important we are to the country and the sacrifices we are doing at this crisis. At the individual level, one needs to incorporate relaxation techniques and positive coping behaviors, eat regular and balanced meals, maintain sleep hygiene, and stay connected with closed ones. Ultimately, this would help to strengthen our resilience to combat the lifethreatening situation.

One of the reasons on how South Korea curbed the COVID-19 spread was due to its excellent coordination between public and private hospitals. Private hospitals contribute a major role in the health care system of any LMICs. Survey studies from Nepal showed that: private sector (hospitals and medical colleges) owns two-third of the hospital beds; roughly half of country's doctors work in a private hospital; majority of patients with acute illness seek care in the private hospital; and out of 480 intensive care unit (ICU) beds available in the capital city of Nepal, 330 beds belong to the private sector. 3, 4 Therefore, the government should collaborate with the private hospital sector to fight against the COVID-19.

The other issue is related to the availability of personal-protective equipment (PPEs). All guidelines recommend PPEs compulsory to the anesthesiologist managing COVID-19 patients. But access to PPEs is far from the reality. For example, according to the COVID-19 rapid response team of our hospital, at present, we have only 140 complete set of PPEs. These PPEs were provided by the Government of Nepal and donors from nongovernmental organizations. The authors correctly pointed out that in today's crisis, LMICs heavily rely on financial assistance from affluent countries and international organizations. 1 While, at this moment, when the rich countries are struggling to get the PPEs for their own health care workers, we will only have a handful of these PPEs by the time it reaches our place. One solution to this is to encourage the local entrepreneurs, innovators, and private sectors to produce PPEs. The government of Nepal has already granted the permission to National Innovation Center to produce PPEs. 5 Although these protective gear might not be of American or European standards, at least, they provide a sense of safety for us. Also, for the decontamination of used PPEs on large scale, the LMICs should develop innovative techniques, such as hydrogen peroxide vapor sterilization. The reprocessing of PPEs followed by its reuse would help us to minimize the shortage.

Finally, the current scenario reminds me of my country's history on how the "Gurkhas" with a curved knife weapon, "Khukuri," fought against the wellequipped forces of the British East India Company. 6 History has repeated again. By the time my opinion gets published in Anesthesia & Analgesia, I will be on the battlefield with "Khukuri" in my hand fighting against the AK-47 (ie, COVID-19 virus). 

The COVID-19 pandemic: effects on low and middle-income countries

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Private gain, public pain: does a booming private healthcare industry in Nepal benefit its people? Available at

Intensive care units in the context of COVID-19 in Nepal: current status and need of the hour

Amid shortage of PPE, National Innovation Centre begins its manufacturing in Bhaktapur